Concomitant Versus Sequential Atrial Fibrillation Ablation and Left Atrial Appendage Occlusion

BACKGROUND: Increasingly, atrial fibrillation patients meet indications for rhythm control with catheter ablation and stroke prevention with left atrial appendage occlusion (LAAO). OBJECTIVE: To assess the frequency of both procedures and compare in-hospital safety of concomitant catheter ablation plus LAAO with cumulative patient-level risk across sequential procedures. METHODS: A retrospective analysis of Medicare fee-for-service beneficiaries with index LAAO (January 1, 2017-June 30, 2024) was conducted. Beneficiaries were classified as LAAO only, sequential ablation and LAAO (±6 months), or concomitant. Procedure utilization and in-hospital outcomes were evaluated. For the sequential cohort, events from both encounters were combined to reflect cumulative patient-level procedural risk. Inverse probability weighted logistic regression compared stroke, major bleeding, and complications between groups. RESULTS: Among 182,582 LAAO recipients, 20.9% underwent ablation during the study period; 7.7% ±6 months, including 1.5% concomitantly. Concomitant and sequential patients were clinically similar; LAAO-only patients were older with more comorbidities. After adjustment, in-hospital stroke and pericardial effusion did not differ. Major bleeding was approximately 50% lower with concomitant procedures (aOR 0.54, 95% CI, 0.42-0.69; p<0.01). Vascular complications were also lower (aOR 0.67, 95% CI, 0.47-0.94, p=0.02). CONCLUSIONS: Concomitant ablation and LAAO demonstrated comparable in-hospital stroke and pericardial effusion risk, but lower observed risks of bleeding and vascular complications compared with cumulative risk across sequential procedures, supporting single-session approach when clinically appropriate.